Anaphylactoid reaction usually related to rate of infusion (can occur with first ever dose)
Flushing, erythema, pruritus, usually of the upper body, neck, face > lower body. Muscle spasms in the back and chest, dyspnea, and hypotension may also occur.
Vancomycin-related linear IgA bullous dermatosis (LABD)
SJS, TEN
Leukocytoclastic vasculitis
Infusion Rate
Slow - lower risk for red man syndrome-----
Fast- higher risk for red man syndrome----
Rate ≤10 mg/min
Dose over ≥100 min
1 gram over ≥1 hour
Rate >10 mg/min
1 gram over <1 hour
Diagnosis
Clinical diagnosis
Tryptase and/or histamine levels after the reaction occurs are not able to distinguish between red man syndrome and IgE-mediated allergy
Skin testing
Not standardized
Reported that a positive ID skin test at 0.1-1 mcg/mL or lower is strongly suggestive of IgE-mediated allergy, while irritant reactions occurred at concentrations ≥10 mcg/mL in controls
Management (Weller)
Prevention of red man syndrome
Infuse over ≥100 min or at a rate ≤10 mg/min, whichever results in a slower infusion
If faster infusion (>10 mg/min or 1 gram over 1 hour) required, consider empiric premedication with oral H1 and H2 blocker (e.g. diphenhydramine 50 mg PO and ranitidine 150 mg PO) 1 hour before infusion
Avoid coadministration of medications that may predispose to mast cell degranulation
Treatment of red man syndrome
Mild - flushing/pruritus that is not bothersome to patient
Stop infusion, when symptoms subside (usually minutes), resume infusion at 1/2 the rate
Moderate - flushing/pruritus withoutchest pain, muscle spasms, or hypotension
Stop infusion, give H1 blocker (e.g. diphenhydramine 50 mg PO or IV); when symptoms subside, resume infusion at 1/2 the rate
For future doses use premedication, consider role of patient's other medications (see table), infuse over at least 4 hours
Severe - pains/spasms or hypotension present
Stop infusion, give H1 and H2 blockers (e.g. diphenhydramine 50 mg IV and ranitidine 50 mg IV), IV fluid if needed
For future doses use premedication, consider role of patient's other medications (see table),
infuse over at least 4 hours
Recurrent red man syndrome despite premedication and slow infusion rate
Consider alternative antibiotics, many patients labeled as PCN-allergic can receive PCN after an allergist's evaluation
Consider for recurrent severe red man syndrome despite premedication or IgE-mediated allergy in patients that can not receive an alternative antibiotic
Vancomycin Reactions
Table of Contents
(Type I)
Infusion Rate
Diagnosis
Management (Weller)
Prevention of red man syndrome
Treatment of red man syndrome
infuse over at least 4 hours
Treatment of IgE-mediated reactions
Desensitization
References